NUR 600 Modules 1-3: Assessment
Techniques & General Survey, Eyes,
Ears, Nose, Mouth, & Throat, Lungs,
Chest wall, Thorax, Heart & Neck
Vessels Peripheral Vascular and
Lymphatics Head, & Neck ,
Question 1
A clinical educator is reviewing the core physical examination techniques with a
group of nursing students. Which of the following statements accurately describes
the clinical value and application of the inspection phase? A. Inspection generally
provides very little objective data regarding the patient's condition. B. Inspection
requires deliberate time to perform properly and uncovers an unexpected wealth of
clinical insight. C. Inspection is typically an uncomfortable physical process for an
experienced practitioner to perform. D. Inspection is meant to be a rapid,
superficial glance at body systems right before initiating palpation.
✔✔ B. Inspection requires deliberate time to perform properly and uncovers
an unexpected wealth of clinical insight.
Rationale: Conducting a focused, systematic clinical inspection demands patience
and yields an immense amount of valuable objective data. Early in their training,
an examiner might feel slightly self-conscious or uncomfortable closely observing
or "staring" at a patient without actively performing a hands-on task. A true
assessment-level inspection is a highly analytical, methodical process that goes far
beyond a simple, rapid glance.
Question 2
Under which of the following physical examination circumstances should the nurse
employ a bimanual palpation technique? A. Evaluating the chest wall and thoracic
compliance of an infant B. Assessing internal organs such as the kidneys and the
uterus C. Detecting cardiovascular pulsations or fine tactile vibrations D.
Identifying localized surface areas of pain and tenderness
✔✔ B. Assessing internal organs such as the kidneys and the uterus
,Rationale: The bimanual palpation method involves using both hands dynamically
to capture, isolate, or envelop specific deep-seated structures or pelvic organs, such
as the kidneys, uterus, or adnexa. Single-handed techniques, finger pads, or light
palpation are much better suited for evaluating infant thoraxes, detecting
vibrations, or mapping out superficial areas of tenderness.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue:
a. turgor.
b. texture.
c. density.
d. consistency. -ANSWER.........C
Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed? The
nurse:
a. percusses once over each area.
b. lifts the striking finger off quickly after each stroke.
c. strikes with the finger tip, not the finger pad.
d. uses the wrist to make the strikes, not the arm. -ANSWER.........A
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly because a resting finger damps off vibrations.
The tip of the striking finger should make contact, not the pad of the finger. The
wrist must be relaxed, and it is used to make the strikes, not the arm.
,When percussing over the liver of a patient, the nurse notices a dull sound. The
nurse should:
a. consider this a normal finding.
b. palpate this area for an underlying mass.
c. reposition the hands and attempt to percuss in this area again.
d. consider this an abnormal finding and refer the patient for additional treatment. -
ANSWER.........A
Percussion over relatively dense organs, such as the liver or spleen, will produce a
dull sound. The other responses are not correct.
The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the
examination. -ANSWER.........D
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality,
and longer in duration are normal over a child's lung.
A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After putting a call in to the physician and placing
the patient on oxygen, which of these is the best action for the nurse to take when
assessing the patient further?
a. Count the patient's respirations.
, b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
-ANSWER.........B
Percussion is always available, portable, and gives instant feedback regarding
changes in underlying tissue density, which may yield clues of the patient's
physical status.
The nurse is preparing to use a stethoscope for auscultation. Which statement is
true regarding the diaphragm of the stethoscope? The diaphragm:
a. is used to listen for high-pitched sounds.
b. is used to listen for low-pitched sounds.
c. should be held lightly against the person's skin to block out low-pitched sounds.
d. should be held lightly against the person's skin to listen for extra heart sounds
and murmurs. -ANSWER.........A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such
as breath, bowel, and normal heart sounds. It should be held firmly against the
person's skin, firmly enough to leave a ring. The bell of the stethoscope is best for
soft, low-pitched sounds such as extra heart sounds or murmurs.
The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation -ANSWER.........A
Techniques & General Survey, Eyes,
Ears, Nose, Mouth, & Throat, Lungs,
Chest wall, Thorax, Heart & Neck
Vessels Peripheral Vascular and
Lymphatics Head, & Neck ,
Question 1
A clinical educator is reviewing the core physical examination techniques with a
group of nursing students. Which of the following statements accurately describes
the clinical value and application of the inspection phase? A. Inspection generally
provides very little objective data regarding the patient's condition. B. Inspection
requires deliberate time to perform properly and uncovers an unexpected wealth of
clinical insight. C. Inspection is typically an uncomfortable physical process for an
experienced practitioner to perform. D. Inspection is meant to be a rapid,
superficial glance at body systems right before initiating palpation.
✔✔ B. Inspection requires deliberate time to perform properly and uncovers
an unexpected wealth of clinical insight.
Rationale: Conducting a focused, systematic clinical inspection demands patience
and yields an immense amount of valuable objective data. Early in their training,
an examiner might feel slightly self-conscious or uncomfortable closely observing
or "staring" at a patient without actively performing a hands-on task. A true
assessment-level inspection is a highly analytical, methodical process that goes far
beyond a simple, rapid glance.
Question 2
Under which of the following physical examination circumstances should the nurse
employ a bimanual palpation technique? A. Evaluating the chest wall and thoracic
compliance of an infant B. Assessing internal organs such as the kidneys and the
uterus C. Detecting cardiovascular pulsations or fine tactile vibrations D.
Identifying localized surface areas of pain and tenderness
✔✔ B. Assessing internal organs such as the kidneys and the uterus
,Rationale: The bimanual palpation method involves using both hands dynamically
to capture, isolate, or envelop specific deep-seated structures or pelvic organs, such
as the kidneys, uterus, or adnexa. Single-handed techniques, finger pads, or light
palpation are much better suited for evaluating infant thoraxes, detecting
vibrations, or mapping out superficial areas of tenderness.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue:
a. turgor.
b. texture.
c. density.
d. consistency. -ANSWER.........C
Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed? The
nurse:
a. percusses once over each area.
b. lifts the striking finger off quickly after each stroke.
c. strikes with the finger tip, not the finger pad.
d. uses the wrist to make the strikes, not the arm. -ANSWER.........A
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly because a resting finger damps off vibrations.
The tip of the striking finger should make contact, not the pad of the finger. The
wrist must be relaxed, and it is used to make the strikes, not the arm.
,When percussing over the liver of a patient, the nurse notices a dull sound. The
nurse should:
a. consider this a normal finding.
b. palpate this area for an underlying mass.
c. reposition the hands and attempt to percuss in this area again.
d. consider this an abnormal finding and refer the patient for additional treatment. -
ANSWER.........A
Percussion over relatively dense organs, such as the liver or spleen, will produce a
dull sound. The other responses are not correct.
The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the
examination. -ANSWER.........D
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality,
and longer in duration are normal over a child's lung.
A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After putting a call in to the physician and placing
the patient on oxygen, which of these is the best action for the nurse to take when
assessing the patient further?
a. Count the patient's respirations.
, b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
-ANSWER.........B
Percussion is always available, portable, and gives instant feedback regarding
changes in underlying tissue density, which may yield clues of the patient's
physical status.
The nurse is preparing to use a stethoscope for auscultation. Which statement is
true regarding the diaphragm of the stethoscope? The diaphragm:
a. is used to listen for high-pitched sounds.
b. is used to listen for low-pitched sounds.
c. should be held lightly against the person's skin to block out low-pitched sounds.
d. should be held lightly against the person's skin to listen for extra heart sounds
and murmurs. -ANSWER.........A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such
as breath, bowel, and normal heart sounds. It should be held firmly against the
person's skin, firmly enough to leave a ring. The bell of the stethoscope is best for
soft, low-pitched sounds such as extra heart sounds or murmurs.
The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation -ANSWER.........A
